Appendix Form #12

• Author: Jerold I. Horn
• Profession: Lawyer
• Pages: 803-804

803

[Power of Attorney for health care. Designed to promote ultimate exibility.]

Power of Attorney

I, JOHN X. STEVENS, of Peoria, Illinois, appoint my wife, JANE H. STEVENS,

or, if she is unable or unwilling to serve, my daughter, AMY B. STEVENS, to be my

attorney-in-fact (“Agent”) to act for me and in my name (in any way I could act in

person) to make any and all decisions for me concerning my personal care, medical

treatment, hospitalization and health care and to require, withhold or withdraw

any type of medical treatment or procedure, even though my death may ensue.

My Agent shall have the same access to my medical records that I have, including

the right to disclose the contents to others. My Agent also shall have full power to

direct the disposition of my remains.

I intend hereby to confer upon the Agent the most comprehensive powers pos-

sible for me to give in connection with the foregoing.

I signed this Power of Attorney this November 1, 2017.

_____________________

JOHN X. STEVENS

The principal has had an opportunity to review the above form and has signed

the form or acknowledged his or her signature or mark on the form in my presence.

The undersigned witness certies that the witness is not: (a) the attending physi-

cian or mental health service provider or a relative of the physician or provider;

(b) an owner, operator or relative of an owner or operator of a health care facility in

which the principal is a patient or resident; (c) a parent, sibling, descendant or any

spouse of such parent, sibling or descendant of either the principal or any agent

or successor agent under the foregoing power of attorney, whether such relation-

ship is by blood, marriage or adoption; or (d) an agent or successor agent under

the foregoing power of attorney.

Dated: November 1, 2017.

_____________________

(Witness Signature)

Appendix Form #12